Monday, December 29, 2008

So Clink, I think, is climbing somewhere. Roy is working, a lot. I'm on vacation (mostly---if you have an appointment with me this week, keep it, I'll be there) and I don't have much to say about psychiatry at the moment. I've had a few thoughts to write about sliding fees, but it's the holidays and a recession, do we really want to talk about money? No. I've thought of writing about the limits of 'evidence-based medicine' in psychiatry. But it's the holidays.

Instead, I'll tell you about my trip to New England last week. I posted from the airport, so you know my plane was delayed-- there was a blizzard where we were landing and the airport closed. One of my kids was pleased that the delay gave her time to get Starbucks, the other remained plugged into an iPod and read a book. I blogged, Starbucks'd, and read the Sunday NY Times, then tried to re-route us, only to be informed that we'd be taking off shortly.

So across the aisle on the delayed and not-quite-full flight, there was a young mom with two very sweet girls. The mom was frazzled. For starters, she was traveling alone with the girls, one of whom had to use the restroom just as the flight was about to take off... a no-no in these post 9/11 days but this family was so...well, let's just say she made it, scooped up in mom's arms.

But the big story was the globe, a big talking globe in a great big box. Mom was trying to navigate the globe, navigate the children, put the globe away. A gift from an aunt...oh, I've been there with the way-too-big to travel with gifts. So mom tries to maneuver the globe into the overhead luggage bin. It does fit. She pushes and pushes and pushes some more, but the talking globe just doesn't fit and I wonder if she's going to break the airplane. It doesn't fit under the seat. She asks the people in the row in front of us if the talking globe can have the empty seat between them. The globe gets buckled in, with it's tray table in the upright and locked position. The flight attendant starts to scold the people sitting next to the globe, who look at her a bit cluelessly, and ultimately, just this once, the talking globe is permitted to have it's own seat, just as the little girl is permitted to use the restroom facilities. Mom borrows a pen from my husband. Twice. She mentions that she's going to Vermont and that she hasn't driven a car in twenty years-- I don't know the details, just that we'll be landing in a blizzard. Mom borrows my husband's cell phone just as we land.

Okay, it would be nice to say I didn't laugh out loud, but as I watched her try to get that talking globe gift from the aunt into different overhead luggage compartments.....

May your holidays be peaceful and filled with joy. May your gifts all fit in your bags. May you enjoy the company of fine friends and fine food.

Saturday, December 27, 2008

I'm back from my White Christmas, back to muddy Maryland. I'm trying to find something stimulating to blog about with my brain on psychiatric vacation. Judith Warner of the New York Times has been kind enough to help with her op-ed piece "Living the Off-Label Life." She talks about a Shrink Rap favorite topic: the line between distress and illness, the use of medication (or in this case, non-meds such as coffee ...Clink....diet, etc) to help people reach some idealized potential. Ms. Warner writes:

------What if you could just take a pill and all of a sudden remember to pay your bills on time? What if, thanks to modern neuroscience, you could, simultaneously, make New Year’s Eve plans, pay the mortgage, call the pediatrician, consolidate credit card debt and do your job — well — without forgetting dentist appointments or neglecting to pick up your children at school?

She goes on to discuss an article in Nature:

That’s why when Henry Greely, director of Stanford Law School’s Center for Law and the Biosciences, published an article, with a host of co-authors, in the science journal Nature earlier this month suggesting that we ought to rethink our gut reactions and “accept the benefits of enhancement,” he was deluged with irate responses from readers.

“There were three kinds of e-mail reactions,” he told me in a phone interview last week. “ ‘How much crack are you smoking? How much money did your friends in pharma give you? How much crack did you get from your friends in pharma?’

But Greely and his Nature co-authors suggest that such arguments are outdated and intellectually dishonest. We enhance our brain function all the time, they say — by drinking coffee, by eating nutritious food, by getting an education, even by getting a good night’s sleep. Taking brain-enhancing drugs should be viewed as just another step along that continuum, one that’s “morally equivalent” to such “other, more familiar, enhancements,” they write.---------

Wednesday, December 24, 2008

In my post “Who Is A Criminal?” one anonymous commenter posted a link to a newspaper story about a former musician who died of benzodiazepine withdrawal in a Cleveland jail. The anonymous commenter wondered what I thought about the story.

Over the course of the years it's not unusual for people to send me links, both on and off the blog, to stories about horrible things that have happened in a jail or prison and to ask my opinion about it. The link usually comes in an email with the subject heading, "Can you believe this???" or "Does this really happen???" The expectation seems to be that I'm supposed to either share their outrage or else defend some obviously horrible outcome.

I do neither, mainly because I don't know anything particular about the case in the media. I do know that the full story never gets reported because facility administrators and staff are bound by confidentiality (or by their attorneys) so the only information public hears about is the horrible stuff.

That being said, Anonymous Commenter followed up the comment with a few specific good questions that I'm answering here.

The Anonymous Questions are:

1. Is what happened to Sean Levert a symptom, in your view, of a tendency by prison administrators to treat psychiatric illnesses as not 'real' -- or was it an exception to the norm?

Clink responds: I can't comment on the Levert case specifically since I don't know the facts of the case. Most prison officials and correctional officers I've worked with don't have any trouble acknowledging that psychosis is a real illness. Sometimes they (and my patients) aren't always up to date regarding information about the medical nature of clinical depression and I've educated people about that.

2. The new Cuyahoga jail policy includes weaning prisoners off benzodiazepines. What's your take on this -- considering that these are relatively short-term prisoners, is it appropriate for a clink shrink to change the drug therapy? Is it appropriate for a shrink to go along with a policy designed, it would seem, less on therapeutic reasons than on convenience to the prison?

Clink responds: Correctional psychiatrists don't prescribe based on length of time in jail because we don't have any way of knowing who the short-timers are. We don't generally know trial dates, pretrial hearing dates, parole or probation hearing dates or mandatory release dates. Regarding prescribing practices, I blogged about this quite a while ago in my post "Change Is Good" so I won't be completely repetitive here. The short story is that there are valid clinical reasons to change someone's medicine that have nothing to do with cost or policy. Medication needs change depending on the environment. Someone with diabetes will need less insulin in a hospital because he'll be getting a controlled diabetic diet and won't have access to off-diet goodies. Prisoners will need less (and sometimes no) medication once they are abstinent from drugs and alcohol in a controlled environment. Sometimes the free society treatment is being provided by a non-psychiatrist and it just frankly doesn't make sense or is inadequate. There are too many hypothetical possibilities to cover them all, but those are the most common reasons why I change medications. The other thing to be aware of---and this is a bit different from free society medicine---is that you're not prescribing for an individual, you're prescribing for an institution. Anything you give to one inmate will eventually end up in the hands of another. For example, if you use tricyclic antidepressants liberally as a sleeping pill you will eventually have an institution filled with medication that is potentially lethal in overdose. Or that can be bad for someone with liver disease (and lots of my folks have hepaitits). There are valid institutional reasons for certain prescribing policies.

3. If a prisoner comes in with a current diagnosis, how much weight do you give that in determining your treatment? Do you defer to the previous doctor, or consider yourself to be starting from scratch?

Clink responds: It depends upon who gave the current diagnosis. First of all, most of my patients weren't getting treatment prior to incarceration. And for those who say they were in treatment, in the majority of cases that treatment can't be confirmed. I once scrupulously collected records for my patients for about four months, when I was new to corrections. Eventually I found that record collection was a futile activity for three reasons: 1. Most of my releases were returned with the comment 'unable to locate patient'---ie., they were never in treatment like they said they were, 2. The records gave me information I already knew from taking a history, and 3. The information I needed wasn't in the documentation because the discharge summary was dictated by a ward social worker or nurse (and only signed by the psychiatrist) and didn't contain the basis for the diagnosis. So, regarding the weight given to previous diagnosis: If I know the doctor and trust their clinical skills I give significant weight to that. If I've never heard of the person before, or if the patient is completely new to me (never seen during previous incarceration) then I start from scratch. If anything the patient tells me suggests that his clinical circumstances have changed, or if he doesn't seem to be responding to appropriate treatment, I restart from scratch. If there's something about the clinical picture that is inconsistent, I rethink the diagnosis. Clinical circumstances change over time, symptoms can change over time, new information can appear or develop so you just keep an open mind. A psychiatry professor I respect once said (on this podcast) that "A good clinician is someone who makes prudent decisions based on insufficient information". In other words, no clinician every has an entirely complete database to work from so you do the best you can with what you've got.

OK, I hope that answers the Anonymous Questioner. Those were good questions.

Sunday, December 21, 2008

Thought I'd say. I hear there's a blizzard in New England. Oh, I hear that because the airport I'm trying to fly to is closed and so my flight hasn't taken off, grounded for who-knows-how-long and here I am in the airport where I'm trying to decide if I should read the New York Times Magazine or write a blog post. I think I'm going to have time for both....

Friday, December 19, 2008

Bird Dog sent me this post from Dr Joy Bliss over at Maggie's Farm who wrote a piece about a column in the Psychiatric Times from Dec 1 about a female psychiatry resident who developed romantic feelings towards a patient. The resident's supervisor's reaction drew scorn in Joy's post for blaming the resident for the sin of being human:

"Well, I am glad she finally got to Dr. Gabbard, because he is one smart guy. Still, I found her supervisor's reponse deeply disheartening and soulless - if not neutered.

Fact is, as everybody knows, humans are prone to affection, attraction and attachment and there is nothing necessarily different about whether that occurs in a shrink's office, or between a businessman and his secretary, teacher and student, clergyman and congregant, trainer and client, doctor and nurse, lawyer and client, classmates, or business associates and office colleagues. Romantic feelings in offices (like many other emotions) are ubiquitous. Sometimes it's mutual...

When you put people together, things of all sorts happen. Analysts and psychotherapists have the peculiar and challenging task of figuring those things out rather than acting on them."

She got help and referred the patient out, but I thought the post deserved attention so am linking it here. Interesting to read in the comments about the attempt to contact said psychiatrist, a Dr Lindsay Raymer at Baylor.

Thursday, December 18, 2008

The DSM-IV is the standard for diagnosing psychiatric disorders. It lists the disorders and what symptoms a patient needs to have to 'meet criteria' for that disorder. It reads a little like a Chinese Menu-- if you have one/two/however many symptoms from column A and a certain number of symptoms from column B...you get the idea. What's interesting is that it's the Diagnostic and Statistical Manual of Mental Disorders, but there's nothing Statistical about it. The criteria are decided by committees, not by experiments or long-term studies that follow prognosis, not by response to medications, not by the presence or absence of a gene or chemical or abnormal brain structure. Yes, we talk about the genetic predisposition to illnesses and chemical imbalances, but they're all assumed (sometimes by rather strong evidence). We treat brain disorders, but we don't know the precise biological etiology of any psychiatric disorder. (Okay, Huntington's Disease, but that's considered a neurologic disorder that has associated psychiatric manifestations).

So the committees that define the disorders (not statistically) are faced with all kinds of issues, particularly around the inclusion or not of many the things we talk about here at Shrink Rap. Is criminal behavior a psychiatric disorder? Binge eating? Homosexuality (-- homosexuality was removed as a psychiatric disorder some time ago).

So what's a disorder (there are apparently 283 ways to be mentally disordered) and how do we arrive at these decisions? There's the politics of it all, there's insurance reimbursement implications, and I imagine the pharmaceutical companies care how the cards fall. The committee members have to limit their income from pharmaceutical companies during the process of DSM work. To further the controversies of it all, the process has been questioned in terms of how transparent it is and who has access to what goes on in the meetings.

The scientists updating the manual have been meeting in small groups focusing on categories like mood disorders and substance abuse — poring over the latest scientific studies to clarify what qualifies as a disorder and what might distinguish one disorder from another. They have much more work to do, members say, before providing recommendations to a 28-member panel that will gather in closed meetings to make the final editorial changes.

Experts say that some of the most crucial debates are likely to include gender identity, diagnoses of illness involving children, and addictions like shopping and eating.

“Many of these are going to involve huge fights, I expect,” said Dr. Michael First, a professor of psychiatry at Columbia who edited the fourth edition of the manual but is not involved in the fifth.

Wednesday, December 17, 2008

I'll admit this seems like an odd question with an obvious answer. Most people would say that a criminal is anyone convicted of a crime. However, there is a difference between someone who has merely been convicted of a single crime and someone with a pattern of criminal behavior. Repetitive criminals may be psychopaths or sociopaths. Fictional characters like Hannibal Lechter or Tony Soprano are good examples of sociopathic or psychopathic personalities.

It might be a bit disconcerting to know that people like this actually exist and that they've been around for a long time. In 1837 an English psychiatrist named James Pritchard wrote a book entitled Treatise on Insanity in which he described people who lacked the ability to form attachments to others and who were unable to experience normal human affection or emotions. These individuals had little regard for the feelings or rights of others, however they didn't have the hallucinations or impaired cognitive functioning that was seen in other psychiatric disorders. Dr. Pritchard coined the term 'moral insanity' to describe this disorder, which he felt was a defect in area of the brain responsible for moral reasoning. Around this time the American Journal of Insanity (which later became the American Journal of Psychiatry) published several individual case studies of homicide offenders, all of which were entitled "A Case of Homicidal Insanity". They were all essentially just case descriptions of murderers. The letters to the editor of the journal following these case studies debated the validity of 'moral insanity' as a mental illness. The difficulty was that the term 'insanity' implied that from a legal standpoint the criminal should not be held responsible or punished for his behavior. Eventually the term 'moral insanity' was dropped in favor of the term 'psychopath', a term proposed by a Nineteenth Century German psychiatrist.

More recently, the term 'sociopath' has been used instead of 'psychopath'. This latest change happened because people were getting confused by the 'psycho' part of the psychopathy label---psychopathy doesn't mean that the criminal is psychotic. Actually, neither sociopathy nor psychopathy are actual 'official' psychiatric diagnoses in that they can't be found in the Diagnostic and Statistical Manual (DSM). The DSM uses the term antisocial personality disorder (ASPD). Patients with antisocial personality disorder have difficulty with lying, impulsivity, repeated criminal acts, and impulsivity or irresponsibility. The majority of people with ASPD are not psychopaths. Psychopaths represent a minority of severely disordered people who lack emotional attachments or responsiveness. They are narcissistic and are unable to learn from experience. They lack empathy or remorse and are cold, cruel, callous people. This callousness is what distinguishes psychopathy from antisocial personality disorder.

There are a lot of people with antisocial personality disorder---about 3% of the United States population or nine million people. The exact prevalence of psychopathy may never be known because psychopaths usually only come to the attention of clinicians when they are caught committing crimes or when those around them coerce them into treatment. The most skillful psychopaths may not come to the attention of the law and may function successfully as politicians, religious leaders or heads of large corporations.

A screening tool for psychopathy was developed in the 1980's and has been widely used in research and forensic practice. Scores on the Hare Psychopathy Check List-Revised (PCLR-R) have been found to be useful for predicting violence and criminal recidivism. Psychopaths identified by the PCLR-R are being studied through functional neuroimaging in order to identify the physical basis for the disorder. These studies have shown that in psychopaths the part of the brain responsible for processing emotions works differently than in normal people. They also have different physiologic responses to emotion.

There is a genetic component to both ASPD and psychopathy as shown by adoption and twin studies. One large twin study has shown that for severe psychopaths as much as two-thirds of psychopathy can be attributed to genetics rather than environmental influences.For ASPD, the condition originates in childhood. A study done in the 1960's followed children from a mental health center who were referred for evaluation of their behavior problems. The study found that over fifteen years, one-third of the children with conduct disorder grew up to have antisocial personality disorder.

Can psychopaths be treated?

This is a tough question to answer. Psychopaths don't generally seek treatment voluntarily because they aren't bothered by their condition. They must be coerced into treatment or persuaded to participate by engaging their self-interest. For example, by emphasizing that treatment is a condition of parole and is necessary to stay out of jail or prison. Since psychopaths have difficulty learning from consequences, several treatment attempts may be necessary. The treatment must be designed to have open lines of communication between others involved in the psychopath's life in order to ensure truthfulness. There must be clear, consistent and firm boundaries between the patient and the therapist. Psychopaths with a high risk of violent behavior should only be treated in a secure and structured setting like a correctional facility. Psychopaths and people with ASPD are at increased risk of developing other psychiatric conditions such as mood disorders and substance abuse. Medication may be indicated for treatment of these co-existing conditions.

There is no evidence that psychopathy or ASPD can be cured. The goal of treatment is to minimize the impact of the conditions on others and on the patient. For example, one goal of treatment might be to minimize the risk of accidental injury by teaching the patient to recognize situations that trigger dangerous risk-taking behavior. Violence is another focus of treatment with psychopaths; violent behavior can be managed with administrative disciplinary procedures within the correctional facility or through the use of medication.

Specific treatment goals should be set up collaboratively with the patient so that expectations and treatment parameters are clear. The patient's self-identified treatment goal may also reveal his level of insight. When I asked one of my prisoners what he was working on in therapy, his answer was telling. "The truth," he said. "Telling the truth, it's something I've been working on for a while."

Monday, December 15, 2008

One of the more---for lack of a better word-- "interesting" obituaries I've read: D. Carleton Gajdusek, a virologist who won the Nobel prize died. His obit in the New York Times details a life filled with adventure, discovery, and stomach-turning pedophilia. There's cannibalism and smeared human brains in the Amazon, 24-hour-a-day darkness near the Arctic Circle, prison time and sexual activity with children adopted in exotic places. Oh, and his biographer is a psychiatrist, so definitely worth a blog post.

-----

And while we're on morbid topics, apparently you can now buy a coffin from Major League Baseball, complete with the team logo of your choice....Go Red Sox?

Saturday, December 13, 2008

'Tis the season. In the past, I've talked about What to Get Your Psychiatrist for Christmas, Hanukkah, or Kwanzaa. Today, I'm going to talk about gift-giving and gift-getting in general. But this is Shrink Rap, you say, what do presents have to do with psychiatry? Pretty much nothing, except that gifts are often a topic people talk about in psychotherapy. Over the years, as both the listener of many gift-related stories, and outside the office as both a gift-giver and gift-receiver, I've made some observations. If you wanted psychiatry, try another blog and check again tomorrow with Shrink Rap...

Okay, so gifts are always a complicated issue. Before you buy anyone a gift (with very few exceptions, the major one being sweet young children who sometimes actually are excited and surprised), here's what you need to know: you're damned if you do and you're damned if you don't. I'm sorry if I sound kind of cynical. I read an email today from a dear friend and when I mentioned I might bring a local specialty food that I've mailed her before, she responded "We don't really like the Maryland thing." Okay, I guess it's good that I'm not wasting my money and time, but it kind of came off as "I didn' like the gift you sent last year." It got me feeling a bit snarky.

I've collected a lot of gift stories over the years, including one guy I knew who would only give his mother gifts embroidered with her initials so she couldn't return them, only to be disappointed when she never wore them. Oy. Gifts often have an edge of control about them.Sometimes people feel the gift is something the giver thinks the receiver should want, or be interested in, or learn about, or have for his or her own good. The other spin on that would be that the giver has an interest he wants to share with the receiver.

So here is what I've learned:

Some people like to be surprised, and mostly they want to be surprised with the thing they want, and if the gifter doesn't know what the giftee wants, that's hard.

Some people want practical gifts and hate the frivolous.

Some people want frivolous gifts and hate the practical.

It's awkward for many people if you give them a gift that is more elaborate or expensive than what you gave them.

Gift-giving often gets saddled with all kinds of unspoken expectations

If your wife wears a size 18, don't give her a size 4.

I don't have any really great suggestions about gift giving. I do have one suggestion about receiving gifts-- there is one response and only one response that works: "Thank you." Oh, a little more effusive is fine, too. I believe that if you don't like a gift, you should quietly return it, and not mention that fact. If someone is in your face asking if you like it, well.... that's difficult. If it's not returnable, re-gift it to someone on Mars (--and yes, I've had someone casually mention to me that they re-gifted a gift I'd given them...was that necessary?) If it's not returnable, if it's not re-giftable, if it can't be donated to a charity that might appreciate it, then quietly throw it out. If you already have one, if it's the wrong size, if you're allergic to it and will die if you open the box, the safest thing is still to leave it at "thank you."

Wednesday, December 10, 2008

I got stuck in traffic, all alone, just me and NPR, talk radio. There's a story on about the suicide rate in Las Vegas. I didn't know it was higher than the rest of the country-- is that surprising? Oh, but for people who leave, the rate goes down, and for people who enter, the rate goes up. It's like something's in the water there (or maybe in some other substances?)

The study, which will be published in the December edition of the peer-reviewed journal Social Science & Medicine, challenges one of the common attitudes about suicide in Las Vegas, Wray said. There’s a general resistance by Las Vegas leaders to admit the extent of the problem, he said, and suicide prevention is “not at the top of anyone’s agenda.”

“Given the magnitude of the problem, one can argue it should be,” he said.

The study does not answer the Las Vegas version of the chicken and egg conundrum: Are suicidal people attracted to Las Vegas, or does something about the city lead people to kill themselves?

The scenarios that explain the high rate of suicides in Las Vegas vary and need further research, Wray said.

“One would be ‘gambler despair’ — someone visits Las Vegas, bets his house away and decides to end it all,” he said. “Another would be that those predisposed to suicide disproportionately choose Las Vegas to reside or visit. And, finally, there may be a ‘contagion’ effect where people are emulating the suicides of others ... Some people may be going there intent on self-destruction.”

Wray said the evidence points to something about Las Vegas that causes more suicides. The finding that suicide risk remains high in Las Vegas while there are declines in other counties suggests there could be something harmful about the city, Wray said. He also noted the finding that the risk of suicide is reduced when people leave Las Vegas.

“If suicide was really about the people, it seems they would take their suicide risk with them,” he said. Experts have speculated that problems with addiction to gambling and drugs and alcohol, lack of mental health resources and rapid growth also may contribute to the suicide problem.

Monday, December 08, 2008

Today a computer told me that I couldn't use Prozac. More specifically, it said that the use of Prozac was contraindicated in people diagnosed with bipolar disorder. This experience led me to conclude that the only thing worse than having an insurance company tell you how to treat your patient is having a computer tell you how to treat him.

I'm required to use an electronic medical record. I don't generally mind this. The constant typing and the amount of time required for data entry is a pain in the rear, but I know it's the best way to ensure continuity of care between prisons. The problem is that the system also has preprogrammed treatment algorithms. I have no idea where they came from, who decided them and what data they're based on, but they exist. Episodically the computer tries to tell me how to practice.

The computer algorithm has also told me not to use lithium with people who are also on certain blood pressure medications and serotonergic reuptake inhibitors with people who have hepatitis. The computer doesn't say "be careful about this combination because it can cause X, Y or Z problems" or "be sure to watch drug levels more closely with this combination". It says, "Use of this drug is contraindicated in these conditions". Then, in order to continue entering the prescription, you have to click an "acknowledge" button to document that You Have Been Warned.

Truly, this is annoying on so many levels.

It's a CYA maneuver so the nameless Company can say it warned you if anything goes wrong. It's unnecessarily alarmist. It confuses the medication nurses who occasionally check to make sure the meds are OK to dispense. But more importantly, it's just bad information. These medication combinations are still effective, and they can be used safely, you just have to monitor them more closely. The geek who designed the system doesn't know this, he or she just programmed in the information he was told to put in. It probably seemed like a good idea.

And it will be someday, once computers are granted prescribing privileges.

*****************

And now I want an opinion from our readers. It's got nothing to do with psychiatry.

If you make hot cocoa from cocoa powder and other ingredients, instead of using hot water and a bag of cocoa mix, is that considered 'homemade'? Dinah says it's all one and the same. I say it's making cocoa 'from scratch' just like baking a cake without using a boxed mix.

To give you a little background, this Tuesday the Robin Hood Foundation held their annual Heroes breakfast. Each year, Robin Hood honors outstanding New Yorkers for their efforts to improve the community and transform the lives of the city’s underprivileged residents. The four organizations represented by the recipients of the Heroes Awards – Uncommon Schools, Year Up, Community Access and Food Bank for New York City will each receive a grant of $50,000 from Robin Hood. "

Mr. Mayes tells his own story about a tortured past, mental illness, addiction, and rising from it all, in a story full of hope and resilience---

Thursday, December 04, 2008

The National Institute of Medicine has officially encouraged medical training programs to place 16 hour limits on the length of shifts that doctors in training can work. The report produced by NIM also recommends that any resident required to work longer than a sixteen hour shift be required to take a five hour nap before continuing.

So now the biological functions of physicians are being regulated by accrediting bodies and other professional organizations. Imagine the stress: "Sleep, gosh darn it! Sleep or we'll lose our accreditation!"

I totally agree that doctors need a decent amount of sleep in order to be any good to their patients, themselves and their families. I just think it's weird that hospitals have to be forced to acknowledge the biological needs of their doctors.

Another interesting story in the LA Times is a three part series entitled Through Prison Glass. It's a story about a woman, who also happens to be an attorney, who met and married a prison inmate while he was incarcerated in Pelican Bay. Pelican Bay is California's control unit prison (also known as a SuperMax facility). The prisoner in this story is alleged to be a leader of the Aryan Brotherhood and is in SuperMax for a murder conspiracy and other crimes committed inside prison walls.

I think it's an interesting story because I'm always curious about the psychology of women who marry convicted criminals whom they've never even known outside prison. You can read the second part of the series here.

Wednesday, December 03, 2008

So it's been over two and a half years of Shrink Rap, coming up on 900 posts. With the help of our readers, we think we've gotten decent at talking about psychiatry in a way that makes it more understandable than the psycho-babble I read as a medical student. We thought we'd try a book, some way of getting our rambling thoughts together in a more cohesive and organized way.

We've got a proposal together, and even a little interest. It's got a way to go (several review processes) before we're sure it's a go and before we even start the process of writing it! Of course, we have the blog posts to distill it from.

So here's our issue of the moment: The Title.

We've been using Off the Couch -- Three Psychiatrists Discuss Their Work --as a working title. I like it, Clink likes it, Roy doesn't like it, the maybe-would be editor doesn't like it. Roy started with wanting to call it My Three Shrinks (isn't that a famous podcast? Oh, yeah!). The editor-to-be suggested How Psychiatrists Think...but I'm a little uneasy with the idea that how We think might represent our entire field. There are some pretty weird shrinks out there.

Roy free associated for me and here's what he came up with:

Psychiatrists Exposed

Psychiatrists Dissected

The Inner Mind of Psychiatrists

My Three Shrinks

Psychiatric Synapses

Inside the Psychiatrist

Inside the Psychiatrist's Brain

Where's the Couch?

How to Annoy Your Psychiatrist

Sex with Fish

The Mental Life of Psychiatrists

Inside the Alienist Mind

Not Your Grandfather's Psychiatrist

Psychiatry for Dummies

Plain Talk Psychiatry

Psychiatric Folks

The Psychiatric Calculus

How Psychiatrists Think

Tabla Rosa

The Blank Slate: Revealed

The Annotated Psychiatrists

Psychiatrists Three

Psychiatrists Cubed

Psychiatrists Talking Trash

Psychiatrists Talking Shop

Psychiatrists Talk Shop

Psychiatrists Thinking Aloud (or Out Loud)90807

I still like Off the Couch, but if I had to pick from the above, I think I'd choose Plain Talk Psychiatry. ClinkShrink opted for Sex with Fish.

So can you think of a good title? Or put in an opinion on one we've gotten? I like short-- two to four words, if possible, and something catchy. We don't think the word "Shrink" in the title will fly. And the audience-- people interested in mental health issues, patients, family members, students in mental heath professions, health care folks who treat mental illness, but probably not psychiatrists-- it's not a book of rigorous studies, just a conversational walk-through of what we think about and how we think about patients and their problems.

Tuesday, December 02, 2008

"Hm... so I'm not sure it's fair to make psychiatry residents have psychotherapy. After all, nobody made me have a gyn exam or give birth as part of my ob-gyn residency!"

It's been a common theme in our comments, this idea that one needs to walk in the shoes of the patient to truly empathize. One commenter even wanted all med students to have a couple of electroconvulsive therapy (ECT) treatments!

So let me talk for a moment about the whole concept of psychiatric residents having their own personal psychotherapies. It started as part of psychoanalytic training (and remains a requirement in order to become a psychoanalyst). The idea isn't to empathize, or to experience what the patient feels, the idea is that the analyst must understand and work through his own unconscious conflicts in order to effectively work with the patients. He must be able to recognize his own counter-transference, know which issues are his so he isn't projecting them on to the patients, and be aware of his own unconscious motivations and conflicts. It sounds good, I have no idea if it works. I'm also not a psychoanalyst and I've never been in psychoanalysis, so my knowledge is limited, and this whole last paragraph may be a bit off or misstated.

Some residency training programs encourage residents to have their own therapeutic experiences. Where I went to medical school, residents would openly post that they were off to therapy or analysis, and it was both expected and encouraged, and trainees would leave the hospital four and five times a week to lie on the couch. Where I trained as a resident, I was aware that some residents were in therapy, but it was never openly announced in public-- it was something that was either done quietly or on the residents' time-- I believe if a resident working on an inpatient unit announced they had to leave for therapy, it would have been frowned upon during working hours. The residents were expected to be doctoring and leaving th for the hospital for treatment in the middle of the work day was not encouraged.

It's hard to learn therapy. It's a process over time and there's not a great mechanism to watch it unwind. Having it oneself probably provides at least one example, and that can't be bad. Most supervision occurs based on notes or the resident's report and so it is skewed, the supervisor can't always be sure the reporting is accurate or necessarily get a great feel for an unseen patient. Yes, there is "mirror" supervision (where the supervisor watches the resident with a live patient), and this is a terrific learning experience, but there isn't really a way for a trainee to be a fly on the wall of an older, more experience psychotherapist over time. Being your own experiment may help with the learning curve, but I'm not aware of any programs that require it. Is therapy required (as opposed to encouraged) to become a social worker or a psychologist? If so, does the program pay for it, does health insurance, are there discounted ways of getting treatment, or does the trainee pay for it? And for how long and how often?

Does one need to have therapy to be a sympathetic human being? Absolutely not. In fact, one can have years of therapy and still be a creep, while another person can be a wonderful therapist even without having been a patient. Nor does one need to have chemotherapy to understand that cancer sucks, or have AIDS to treat it with kindness. As MWAK has pointed out, many child-free people have delivered wonderful healthy babies and rendered terrific care to their pregnant and delivering mothers without ever having had the experience themselves. And if one has never psychotic, can one truly appreciate the pain it causes: I doubt it. Is it necessary to feel that pain in order to render good care? Of course not.

Sometimes it brings people comfort to know their doc has been there. Substance abuse counselors are often open about their own past histories with drugs. A friend with cancer is now seeing a therapist who is a survivor, and she feels very comfortable with this. I have always been comforted by the idea that my children's pediatrician is himself a father.

But you don't have to have panic disorder to treat it. You don't have to have suffered with depression or schizophrenia or obsessive compulsive disorder to treat it or to appreciate that someone else is suffering.

Should psychiatrists undergo their own psychotherapy?Oh, everyone knows what I'll say: yes, if they want to.I believe that most people who are drawn to being psychotherapists have a somewhat analytic nature. They like to look at patterns and relationships (maybe they even like to blog about them). They are curious about what makes humans act the way they do, and by extension, they are probably interested in what makes their own psyches tick. Furthermore, people who practice psychotherapy tend to believe in it's power, they feel there is value in articulating emotional life and in examining the internal world. Given this, a personal therapy may have some appeal, with or without the presence of a psychiatric disorder. (I'm not going to even touch the question of who should pay for it if the psychiatrist doesn't actually have an illness...). If the psychiatry resident wants to have a personal psychotherapy, he should. If he has a psychiatric illness, he should get treatment. But a psychiatry resident who is not ill, who is not suffering emotionally, and who is able to work and to love and who doesn't want to have psychotherapy should not feel compelled to do so for it's own sake. And, by the way, if he later decides it might be helpful, there's no time limit on when, it's not just for trainees.

Are there studies? I don't know of any that randomly divide shrinks who've been shrunken from shrinks who are unshrunken and then looked at their treatment successes with patients....

On the Web site prayabout.com, Steve’s wife, whose online profile notes that she is a Catholic from St. Charles, Mo., asked other users of the site to submit prayers that her husband will listen to his psychiatrist. She also asked for prayers that the psychiatrist will “see that my husband has major issues that need to be worked on ASAP.”

Monday, December 01, 2008

On a totally different note, I just read the strangest article in the Sunday New York Times. The author has a very detailed discussion of her sex life, of how she's no longer interested in her husband, of her first orgasm, and she mentions her episodes of depression, though not as a cause of her weak libido. I'm not posting a link, I'm not even comfortable citing the author's name. The detail would have been rather intimate if I'd heard it from a friend, or perhaps even a patient, but to read it in the New York Times--- somehow I felt like I was prying. I can't help but wonder how the husband (the no longer interesting former object of sexual desire) must have felt.

Saturday, November 29, 2008

The trend is for psychiatrists to see patients for psychiatric evaluation, treatment with medications, and a medicalized version of psychiatric care, while parceling out psychotherapy to non-MD psychotherapists-- social workers, psychologists, licensed clinical counselors, nurse therapists, pastoral counselors (and anyone else who wants to listen...a bartender or two, perhaps the hair stylist).

Those readers who've been following Shrink Rap for a while know that I work in two types of outpatient settings: a community mental health center where I see people to treat their mental illnesses with medications, and a private psychotherapy practice where I use medications but I also provide psychotherapy to patients who want and need it. ClinkShrink sees patients in forensic settings (name your jail) and she sees a remarkably high volume of patients. She deals exclusively with medical issues-- patients may say or hear things that impact them positively, but the formal setting of therapy to talk, as a process over time, to resolve specific issues, to deal with past events, and to alter patterns of behavior, is not what she does. Roy has worked in many settings, but his current hat is as a Consultation-Liason psychiatrist in a large community hospital-- he mostly evaluates patients and makes treatment recommendations, but he doesn't see outpatients over long periods of time. He used to do that.

Psychiatrists (in the old days) used to see people for psychotherapy routinely, especially before medications were available. I think I was finished with medical school before I even knew that social workers saw clients for psychotherapy. I thought they met with families, worked for agencies, helped with disposition and obtaining benefits, and had a lot to do with foster children and protective services. I believed psychotherapy was the exclusive domain of psychiatrists and clinical psychologists. I simply didn't know.

I've talked here before about why I think, in a totally ideal world, that it's best for patients to see one person for psychotherapy and medications: one stop shopping is more convenient, psychiatric illnesses aren't 'explained' away without the offer of medications, the doc really gets to know the patient and learns to differentiate better what is, and what is not, a symptom of illness or medication side effects, and there isn't a set-up for patients who are prone to dividing their care-takers into good guys and bad guys.

The reality of the world is that psychiatrists are the most expensive mental health professionals, and in the shortest demand. They are more expensive to train, they often finish school heavily in debt, and there aren't enough to go around. And psychiatric residency programs, for the most part, don't emphasize psychotherapy training-- the resident has to pursue it. A psychiatry resident was recently telling me about a patient who wanted insight-oriented psychotherapy and the resident said, "We just don't have time in residency to do that." For those who know they want to pursue a career in research, spending a lot of time learning to do psychotherapy may not be a wise use of limited time. Some people might go as far to say that it's wrong to have psychiatrists doing psychotherapy, especially in shortage regions where there aren't enough shrinks to go around--- a lot more patients can be seen for quick med checks than for 4 times/week psychoanalysis (-- I'm not a psychoanalyst, by the way).

I believe that people should do what suits them, given the realistic constraints of their environment. I'm even okay with the psychiatrist beauty queen. With regard to psychiatrists doing psychotherapy: I like the work and there seems to be a demand for it. I also work in a clinic where the option does not exist to do this kind of work, but it does afford me the opportunity to see a different population of patients and to work as part of a team.

Thursday, November 27, 2008

Does your family know if you want to be put on a ventilator if needed?

Kept alive with i.v. fluids and nutrition?

For how long?

So you have a living will or advance directive?

Can your family find it?

It's a tough discussion to have, but even tougher to discuss when you have a feeding tube in your nose, a breathing tube in your throat, and are unconscious. So, while everyone's enjoying turkey at the table this week, someone bring up the topic so that everyone knows how aggressive to be if you are facing death. The website, Engage with Grace, can help.

Wednesday, November 26, 2008

A while back, one of our commenters took issue with the fact that I referred to a patient's complaint. It got me thinking about the way doctors word things, sometimes in ways that may sound pejorative.

So the standard format of medical notes opens with the "Chief Complaint." If the patient comes in saying things are great, the medical note begins, "patient has no complaints." Often the patient's exact words are quoted. To a physician, this isn't whining, it doesn't have a pejorative edge. The patient's problem is what we are taught to focus on, though a complete medical evaluation includes a review of systems (that's the term) where patients are asked, in a systematic way, about symptoms that may be indicative of a health problem apart from those pertaining to the chief complaint.

In describing patient symptoms, doctors also will sometimes use the statement "patient denies" symptoms. It's sometimes felt that this implies the physician doesn't believe the patient-- patient denies hallucinationsis a different statement than no hallucinations.

And then, of course, there are the subtleties of sorting out how people interpret our rather unusual questions in psychiatry. We ask if people hear voices, and when I started doing this I was surprised at how many people say Yes. I soon realized that it's not at all unusual for people to occasionally hear the voice of a dead relative calling their name--- this is, I believe, a cultural phenomena, and in the absence of other voices or symptoms of psychosis, it's not necessarily a psychiatric symptom or a marker of psychopathology. And we ask people if they ever have the sense that the TV is talking to directly to them-- a symptom we call Ideas of Reference from the media. People sometimes think I'm asking if something said on TV feels like something they can identify with strongly, which is a different phenomena (one that's not a psychiatric symptom) when what I literally mean is--- is someone on the TV speaking specifically and only to you? And assessing paranoia in a city with a mind-boggling crime rate is a task of it's own. The questions have to get pretty specific, and if you're not a little worried, well, that's a little odd.

Almost didn't link to them due to their flagrant {and fragrant} display of malpractice ads in their Google Ad section on the right (see that section in black). Maybe someone can let Stephanie in advertising know that they can tweak their GoogleAdsense settings to exclude certain words, such as "maIpractice", "v1agra", "xan.ax", and "porn". That's what we've done here.

Tuesday, November 25, 2008

Yes, Mrs. United States has an 'M.D.' after her name. She's a psychiatrist. Now THERE was a blog post in the making. I couldn't resist.

According to the APA-sponsored web site Healthy Minds, Dr. Gariane Gunter (a third year psychiatry resident) ran for Mrs. South Carolina and later Mrs. United States on a platform (beauty pageant contestants have platforms??) of advocacy for people with mental illnesses. Now let me say right off the bat that I think it's very cool that she is publicly speaking out on behalf of our patients and doing what she can to call national attention to the problem of psychiatric stigma. She's also participating in a program to teach children and teenagers about psychiatric disorders, an important project given how many are afflicted with them and how cruel teenagers can sometimes be to anybody who's 'different'. Dr. Gunter wants to become a child and adolescent psychiatrist.

My other thoughts about this were two-fold. First, if I were a patient would I want my doctor to be a beauty queen? Ugh, I'd feel obliged to put on makeup for every appointment and I don't wear makeup. (What is it about makeup, anyway, that psychiatrists seem to equate this with mental well-being in women? You always see a mental status exam that notes whether or not someone is 'neatly made-up', as though the use of cosmetics actually meant something diagnostically.) The other thought I had was: 'Wow, and we obsess over revealing too much to our patients in a blog!' I wonder how her swimsuit competition photos went over on the ward, or how this will affect her future private practice. I already know how it would go over in a correctional clinic.

My third and final thought (OK, I had three-fold thoughts. I'm on a roll.) was about the irony of a psychiatrist participating in a beauty pageant while simultaneously educating the public about teen psychiatric disorders. I mean, aren't anorexia and bulemia going to be issues in this audience? Does it send the right message to equate success with physical beauty, while cautioning people about eating disorders? Am I stretching the issue way too far and need to chill out?

Sunday, November 23, 2008

I recently linked to an article on the Well Blog about a child with Asperger's Syndrome in NYC. The boy's parents were at odds with their housing co-op about the boy's need for an emotional support dog in the no-pets-allowed complex.

Roy said that's what docs get to do: determine medical necessity.Commenters on our blog and the Well blog were mixed, and I really don't have enough facts to feel comfortable commenting on the situation.

It did get me thinking about the concept of Medical Necessity and before I start rambling, let me say that I didn't see the term "medical necessity" on anything associated with the kid and dog case. What I read simply said that doctors thought a dog would help the boy, that the co-op agreed to let him have a small dog with many stipulations attached, and the feds, specifically HUD, took on the cause and felt the co-op discriminated against the family. You can read Here.Medical Necessity is a funny concept, one I'm not always 100% comfortable with. I think the issue here is that when we as physicians deem something Medically Necessary, it implies some imposition, usually financial, but in the case of the service dog--furry-- on someone else. Usually we use the term to mean that it's something someone's health insurance should pay for that they don't (or may not want to) pay for. If there's not a cost (financial or otherwise), then one can leave it at "My doctor said to do ...." and there's not a reason to deem it "medically necessary." That's a term that goes in writing and means someone, somewhere will find it inconvenient.

I don't usually declare that things are Medically Necessary from a psychiatric viewpoint, except for specific medications-- sometimes Name Brands (as opposed to generics) and then because the patient has tried the generic and found that either they don't work as well or they cause side effects. The other Medically Necessary things I recommend are sessions (ie, treatment is medically necessary) or Hospitalization...ah, the joys of managed care. Sometimes I tell people to stay home from work, especially if I feel their behavior during an episode of illness puts them in jeopardy, and I'll write a note saying they need time off, or that they were at a doctors' appointment, but this usually doesn't require a statement of medical necessity, per se, it falls under sick leave. My stationery doesn't even say I'm a shrink, and unless I'm specifically asked, I don't volunteer that in "doctor's excuse" notes.

In the case of the dog and the kid, the term "medically necessary" wasn't used-- it was simply said that the dog might be helpful to the boy. What about another occupant who might require a animal-free environment? How do we determine whose rights trump whose? Maybe this is a bad example, because one can envision that one condo owner could live with a dog in such a way that the other people in the condo aren't disturbed by it and the presentation by the press left the reader feeling that the complex owners are unsympathetic child and dog hating meanies who were being unnecessarily arbitrary. I got curious and did a little googling-- it seems the dog would be going through a training process with the boy. The other issue was concern by the building about the area around the entrance to doctors' offices in the building.

So this is my concern with extending the definition of what is a disabilty and what we should do as a society to accommodate the needs of the disabled: if the issues get too diffuse, then ultimately the laws to protect the disabled hurt them. Don't want any autistic kids here because then we'll have to allow their dogs. Okay, maybe that's silly, but the issue isn't just what one group needs, it's also the fear of being sued because of the perception of injustice, or the fear of having to accomodate. The issue of medical necessity feeds into this unless we hold to a fairly strict notion of what is medically necessary, and as doctors.

If you want to read more about the kid with the battle for the dog:Try this or this.

And just to be clear, this is a rambling post. Most often, 'medical necessity' is a term that has to do with Medicare reimbursement...somehow I've gone off about service dogs and co-ops and broader implications to society.

Thursday, November 20, 2008

Our thanks to Healthskills who passed along the Kreativ Blogger Award to us!

I've been reading your blog for a while - this is a great post, as is the previous one on DSM v.

I've passed on the Kreative Blogging award to you, as I love to read your site.Congratulations!

Head to http://healthskills.wordpress.com to see what I wrote - basically you list 6 things you love, then nominate six blogs for the award. It's fun, and creates some great links you might never have made before!Six things I love? Can I do this for my co-bloggers?And six blogs? How do I choose? I read Fat Doctor faithfully, sometimes I check on FooFoo5, and often I see what KevinMD is blogging about. I sometime check The Last Psychiatrist but he often annoys me. There's the Well blog over at the NYTimes, but I don't think Tara Parker Pope is looking for awards from me. And I often check out the blogs of some of our commenters, by all means keep leaving links-- I hate to mention one without mentioning them all....

Wednesday, November 19, 2008

So a new patient presents with the usual chief complaint of: "I'd like to enter psychotherapy so I can better understand myself, my motivations, my patterns of behavior, and resolve any unconscious conflicts that may be hampering my ability to live life fully." Patent after patient, all day long.

In case you didn't catch my sarcasm, no one has EVER presented (to me) with such a request, perhaps because I'm not a psychoanalyst? People come because:

They are having psychiatric symptoms such as sustained sadness, irritability, panic attacks, anxiety... fill in the blank ....

--or--

Bad things are happening in their lives and they are having trouble coping.

So Roy has been talking about CPT coding-- the codes psychiatrists submit to insurance companies that explain what we do to get reimbursed-- and about new Diagnostic Criteria in the making. We talked about CPT coding on our soon-to-be released My Three Shrinks Podcast, and it got me thinking:

What makes it Psychotherapy? Roy pointed out that there is felt to be a problem with the CPT code 90862-- Medication Management, a code unique to psychiatry. The reimbursement is the same if you spend 5 minutes or 500 minutes with the patient managing their medications, there are no gradations, and clearly the slant is to pay docs more to see more patients for less time each. You can call it psychotherapy, and then time figures in-- there are codes for 25 minute therapy sessions and 50 minutes therapy sessions, but it all got me thinking.

So like what does make it psychotherapy? If a patient walks in the door for a session that is scheduled as a medication management session and the doctor asks, "How are you?" and the patient starts talking about a stressful circumstance they are dealing with in their lives and feels helped by the brief session: is that psychotherapy? How long does the session have to last? How regularly does it have to occur? Many people want sessions every other week or once a month because they can't afford weekly, or twice weekly, sessions or they can't logistically make the time in their lives. Other people don't even want to schedule that regularly, they call when they want to come in and the frequency of sessions varies with how they are doing. Even with irregular sessions, many people do really good work and make really substantial changes in how they deal with the world or how they let the world deal with them, and they find the sessions helpful, but it may not be an on-going process.

So what does make it therapy? The Psychiatric Times front page article this week is called The Decline of Psychotherapy-- it takes info from National Trends in Psychotherapy by Office-Based Psychiatrists Mojtabai and OlfsonArch Gen Psychiatry.2008; 65: 962-970.and it goes into statistics on how many (or how few) psychiatrists do therapy with all or some of their patients, all or some of the time, now versus way back when.

Psychotherapy is a treatment where the talking is part of the cure. From the best I can figure, if the psychiatrist calls it therapy, and the patient calls it therapy, then whatever transpires between the two is therapy, and hopefully someone finds it helpful.

Monday, November 17, 2008

Christopher Lane over at the LA Times has an Opinion published in yesterday's issue exposing the debate within the APA (now spilling out) about how transparent to make the process for developing the upcoming DSM-V.

...The bone of contention: whether the next revision of America's psychiatric bible, the "Diagnostic and Statistical Manual of Mental Disorders," should be done openly and transparently so mental health professionals and the public could follow along, or whether the debates should be held in secret.

One of the psychiatrists (former editor Robert Spitzer) wanted transparency; several others, including the president of the American Psychiatric Assn. and the man charged with overseeing the revisions (Darrel Regier), held out for secrecy. Hanging in the balance is whether, four years from now, a set of questionable behaviors with names such as "Apathy Disorder," "Parental Alienation Syndrome," "Premenstrual Dysphoric Disorder," "Compulsive Buying Disorder," "Internet Addiction" and "Relational Disorder" will be considered full-fledged psychiatric illnesses.

Perhaps some think that this is another thing, like making sausage or legislation, that one doesn't want to know how it is made or what goes into it. Let's hope not. In fact, Robert Spitzer, who chaired the group which created the third edition of the DSM (the so-called Diagnostic & Statistical Manual contains the gold standard definitions of various mental illnesses and other conditions), sent out an open letter a few months ago calling on the APA to open up the process. In response, the APA is now publishing Work Group reports and is planning to publish the minutes from the meetings, as well.

Sunday, November 16, 2008

It's been months, literally.
We've done two that haven't been posted yet-- fortunately it's psychiatry and not the Dow Jones Industrial average, or gas prices, so they're not terribly time-sensitive. But Roy didn't want to put them up as if we'd just done them, so we made a new one this evening.
Clink had come from climbing.
Roy and I had been battling it out at Risk.
Stay tuned.....
[Edit: So it took a year :-( Anyway, check out #48: Genital Retraction Syndrome. -Roy]

A legal battle in New York City highlights the healing power of dogs for children with autism and Asperger’s syndrome.

Manhattan federal prosecutors have accused the owners of an Upper East Side residence of discriminating against 11-year-old Aaron S by preventing him from having a dog, The New York Daily News reports.The report goes on to explain:

According to the newspaper, a lawsuit claims the building owners violated the Fair Housing Act by imposing unreasonable demands on Aaron’s parents before allowing a dog. Among the restrictions reportedly imposed by the building: the dog couldn’t be left alone for more than two hours, it would have to be taken in and out of the building on a service elevator, monitoring of dog walkers who might take it for a stroll, and $1 million in liability insurance for any injury or property damage caused by the dog. A company-hired doctor reportedly agreed the dog was medically necessary.